This protocol addresses the inpatient management of nonsevere community-acquired pneumonia (CAP) in adults aged 18 years or older who lack specific risk factors for resistant organisms.
The patient is an adult (age 18 years or older) hospitalised for nonsevere CAP, with no prior respiratory isolation of MRSA or Pseudomonas aeruginosa, and no recent hospitalisation involving parenteral antibiotic receipt in the preceding 90 days.
The primary endpoint is clinical stability: resolution of vital sign abnormalities (heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature), return of the ability to eat, and normal mentation. Most patients reach stability within the first 48–72 hours.
Evidence-based management centres on antibiotic therapy — either a combination regimen pairing a beta-lactam with a macrolide, or monotherapy with a respiratory fluoroquinolone. An alternative pathway exists for patients with contraindications to both of those classes. The complete regimen, agent selection, step-down criteria, and duration guidance are in the full protocol.
DOI: 10.1164/rccm.201908-1581ST
In inpatient adults with nonsevere CAP without risk factors for MRSA or P. aeruginosa (see Recommendation 11), we recommend the following empiric treatment regimens (in no order of preference) (Table 4):
combination therapy with a b-lactam (ampicillin + sulbactam 1.5–3 g every 6 h, cefotaxime 1–2 g every 8 h, ceftriaxone 1–2 g daily, or ceftaroline 600 mg every 12 h) and a macrolide (azithromycin 500 mg daily or clarithromycin 500 mg twice daily) (strong recommendation, high quality of evidence), or monotherapy with a respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily) (strong recommendation, high quality of evidence).
A third option for adults with CAP who have contraindications to both macrolides and fluoroquinolones is: combination therapy with a b-lactam (ampicillin + sulbactam, cefotaxime, ceftaroline, or ceftriaxone, doses as above) and doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence).
In switching from parenteral to oral antibiotics, either the same agent or the same drug class should be used.
We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence).
As most patients will achieve clinical stability within the first 48 to 72 hours, a total duration of therapy of 5 days will be appropriate for most patients.
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